Health Tourism Patient Information Form

Please Note: there are 7 steps to go through to complete the patient information form. Please fill in all the fields below to continue to the next step.

* All information obtained will be treated with the strictest confidence.

* The information obtained will be used solely for communication between medical practitioners and specialists.

* All patients should bring with them, copy of all material records including all X-rays and blood investigation results before any procedure can be done by our South African doctors.

Step1: Personal Details

* Name:

* Surname:

* Gender:

Male

Female

* Physical Address:

* Work Address:

Passport Number :

* What is your budget for medical services in South Africa?

Please note: all fields with * are mandatory:

* Country of Origin:

* Age:

* Country Code + Home Telephone Number:

* Country Code + Work Telephone Number:

* Country Code + Cellphone Number:

* Current occupation:

* Employer/business name:

E-Mail Address:

* All information obtained will be treated with the strictest confidence.

* The information obtained will be used solely for communication between medical practitioners and specialists.

* All patients should bring with them, copy of all material records including all X-rays and blood investigation results before any procedure can be done by our South African doctors.

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